Provider Demographics
NPI:1609589480
Name:JACKSON, KIERRA
Entity Type:Individual
Prefix:
First Name:KIERRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BAYBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-1817
Mailing Address - Country:US
Mailing Address - Phone:912-689-6970
Mailing Address - Fax:
Practice Address - Street 1:118 BAYBRIDGE DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-1817
Practice Address - Country:US
Practice Address - Phone:912-689-6970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P4000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPatient Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA053324374OtherID